STATE OF SOUTH CAROLINA DEPARTMENT OF REVENUE APPLICATION FOR FOOD MANUFACTURER'S LICENSE ABL-903 (Rev. 7/3/03) 4309 For Office Use Only Mail to: SCDOR, ABL Section, Columbia, SC 29214-0908 Telephone: (803) 898-5864 DOR Website: www.sctax.org File Number License Period Ending 8/31 DLN PLEASE PRINT OR TYPE ALL INFORMATION DLN Nonrefundable Filing Fee License Fee Total Fees $ 1400.00 $ 1600.00 14-3975 $ 200.00 SLED 1. Owner, Partnership, or Corporate Charter Name 2. 34-3973-9100 Physical Location of Business Required (No P.O. Box) STREET CITY 3. COUNTY (REQUIRED) STATE ZIP STATE ZIP Mailing Address (For all Correspondence) STREET CITY 4. COUNTY Type of Ownership Sole Proprietor (one owner) Partnership (two or more owners) SC Corporation Date Inc. Non-Profit Organization LLC/LLP Foreign Corporation (Attach copy of Articles of Certificate of Authority) Other (Explain) 5. Trade Name (Doing Business As) 6. Business Phone Number 7. Federal Identification Number and/or Social Security Number 8. Location of Records (No P.O. Box) Daytime Phone Number Applicant (owner, partner, or corporate officer) Section 61-6-710. Notwithstanding any other provision of this title, a person who manufactures in this State food items such as sauces and marinades in which there is an alcoholic beverage ingredient and who does so under an agreement with the alcoholic beverage manufacturer must apply for a special food manufacturer's license from the department, in accordance with Section 61-2-100, to purchase the alcoholic beverage directly from the manufacturer in containers holding greater quantities of liquor than are sold to a retail consumer. The department must establish the form of the application for the special food manufacturer's license." Social Security Privacy Act Disclosure It is mandatory that you provide your social security number on this form. 42 U.S.C 405(c)(2)(C)(i) permits a state to use an individual's social security number as means of identification in administration. SC Regulation 117-1 mandates that any person required to make a return to the SC Department of Revenue shall provide identifying numbers, as prescribed, for securing proper identification. Your social security number is used for identification purposes. American LegalNet, Inc. www.FormsWorkflow.com